Meds still being given to the wrong patients

Is your staff following the ‘8 rights’?

When you look at wrong-patient medication errors and compare current and past reports, one point is obvious: These events still are occurring, says Rodney W. Hicks, PhD, RN, FNP-BC, FAANP, FAAN, professor in the College of Graduate Nursing at Western University of Health Sciences, Pomona, CA.

Hicks spoke on the topic of medication safety at the recent Ambulatory Surgery Center Association (ASCA) annual meeting.

The Pennsylvania Patient Safety Authority recently released a report saying 813 wrong-patient medication errors were reported between July 1, 2011, and Dec. 31, 2011. Many errors were reported in transcribing (38.3%, n = 311) and administration (43.4%, n = 353). While the authority acknowledges that many factors contribute to medication errors, the most common factors were two patients being prescribed the same medication, improper verification of patient ID, and similar room numbers. The most common types of medications associated with wrong-patient events were anti-infectives, insulin, and anticoagulants.

The fewest errors were reported during dispensing (5.2%, n = 42) and prescribing (12.1%, n = 98).

Improvements in prescribing is one of the success stories, says Hicks, who was the lead author of a 2008 USP/MedMarx data report titled “A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.” In that 2008 report, 29.6% of errors were reported in prescribing, Hicks says. The improvement in those statistics might reflect the increased use of electronic prescribing, he says. However, when physicians have the ability to go into an electronic system and select a patient, there is always a danger, he says. “The biggest threat to that is what do you do when you have patients with multiple same names, like Smith? How do you make sure you get the right Smith?”

If the physician is not next to the patient or the physician is writing the orders remotely, that is a risk point, Hicks says. “When we rely on memory, as providers, we think we’re doing the right things, but humans are fallible and make mistakes from their memory,” he says.

Have a “name-alert” policy for how your facility handles patients with similar or the same name, Hicks advises. Also, expand the former nursing adage of the “5 Rights” before medication administration, which are right patient, right time, right drug, right dose, and right route. Now, nurses must follow the “8 Rights,” which includes the previous five, plus right indication, right documentation, and the right to refuse. Tips offered by the Pennsylvania authority are ensuring proper storage of medications and patient-specific documents, using healthcare technology fully, limiting verbal orders, and improving patient verification throughout the medication-use process.

Also, providers should ensure proper storage of medications and patient-specific documents, and they should empower the patient to prevent and detect medication errors, the authority says. Some additional tips offered by Hicks are to assess staff impact on medication errors. Minimize cross-coverage, and minimize floating staff, he advises. Additionally, look at distractions specific to your facility, Hicks suggests.

“In day surgery, you typically don’t have high volumes of patients, so being able to explain why the wrong person got the medication is baffling,” Hicks says.


To obtain the advisory from the Pennsylvania Patient Safety Advisory titled Wrong-Patient Medication Errors: An Analysis of Event Reports in Pennsylvania and Strategies, go to